Health inspection·January 17, 2025

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on observation, interview, and record review, the facility failed to obtain a Level 2 screening for a resident newly diagnosed with severe mental illness to determine if there was a need for specialized mental health services. This failure effects one resident (R2) out of two residents reviewed for pre-admission screening on the sample list of 27. Findings include: On 1/14/25 at 11:04 AM, R2 was lying in bed in his own room. R2 was speaking in a hyper-manic pattern and was unable to maintain the topic of conversation. R2's Census Detail documents R2 was admitted to the facility 10/12/2006. R2's Interagency Certification of Screening Results dated 8/16/06 documents R2 did not qualify as being developmentally disabled, and there was no reasonable basis to suspect a mental illness. R2's Medical Diagnoses List documents R2 was diagnosed with Delusional Disorder (Severe Mental Illness) on 1/26/21, and Affective Mood Disorder (can be included as severe mental illness) also on 1/26/21. There was no documented screening for Level 2 services for R2 in the medical record after the date of these new diagnoses. On 1/15/25 at 11:35 AM, V1, Administrator, displayed her computer screen for the (pre-admission screening service provider) and stated the only pre-admission screening showing up was on 8/16/06 and there was no Level 2 screen in the system. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0661 Level of Harm - Minimal harm or potential for actual harm Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interview and record review the facility failed to complete a discharge summary for one (R48) resident out of one resident reviewed for discharge in a sample list of 27 residents. Residents Affected - Few Findings include: The facility policy titled Discharge Summary revised 11/5/2019 documents a discharge summary shall be prepared for each resident discharged from the facility. When the facility anticipates a resident's discharge to a private residence or to another nursing care facility a discharge summary will be developed which will assist the resident to adjust to his or her new living environment. R48's Electronic Medical Record (EMR) documents R48 admitted to facility on 6/30/22 and discharged on 10/21/24. R48's Care Plan initiated 2/26/24 documents (R48) wishes to be discharged but has no supportive family/caregivers. (R48) is independent and mostly requires verbal cues for task completion as well as medication management due to intellectual disability related cognitive deficits. R48's Medical Record does not include a discharge summary/recapitulation of stay, Physician order for discharge nor nurse progress note documenting R48's discharge. On 1/15/25 at 1:30 PM V1 Administrator stated the facility does not have any documentation of a discharge summary and/or recapitulation of stay. Physician order for R48's discharge nor any nurse progress notes documenting R48's discharge. V1 Administrator stated R48 requested to move to another Skilled Nursing Facility (SNF), so a referral was sent and R48 moved to that SNF. V1 stated there is no documentation due to this facility was purchased by another corporation on 11/1/24 so all the resident information was given to the old facility corporation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during wound care for one (R24) resident's left plantar heel open diabetic ulcer, failed to monitor R24's left heel diabetic ulcer and failed to follow physician orders for R24's left heel wound treatments for one of two residents (R24) reviewed for skin conditions in a sample list of 27 residents. R24 experienced the worsening of her left heel open wound due to dressing changes not being completed per physician order and not being provided timely incontinence care which led to R24's dressing to be fully saturated with wound drainage and urine which required antibiotics due to a Staphylococcus (Staph) infection. Residents Affected - Few Findings include: R24's medical diagnosis list documents medical diagnoses of Acute Osteomyelitis of the Left Ankle, Diabetes Mellitus Type II with foot ulcer, Morbid Obesity and Polyneuropathy. R24's Minimum Data Set (MDS) dated [DATE] documents R24 as cognitively intact. This same MDS documents R24 requires maximum assistance for toileting and moderate assistance for personal hygiene. R24's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 12/24/24 of left plantar heel: Cleanse with Normal Saline, apply nickel thick Santyl (chemical debriding agent) to wound bed. Cover with absorbent pad and secure with gauze roll daily and as needed if loose or soiled. R24's POS documents a physician order starting 1/3/25 and ending 1/13/25 for Amoxicillin 875 milligrams (mg) Give 875 mg by mouth two times a day related to non-pressure chronic ulcer of Left Heel and midfoot. R24's Skin Integrity care plan initiated 8/24/24 documents (apply) dressing to (R24's) Left Foot. Observe dressing every shift. Change dressing and record observations of site daily. R24's care plan intervention dated 4/3/24 instructs staff to provide incontinence care as needed. This same care plan documents an intervention dated 4/3/24 to monitor, document and report and signs and/or symptoms of infection. R24's Weekly Wound Log dated 12/24/24 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 11.6 centimeters (cm) long by 5.0 cm wide by 0.8 cm deep. R24's Weekly Wound Log dated 12/31/24 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 11.8 centimeters (cm) long by 6.0 cm wide by 0.8 cm deep. R24's Weekly Wound Log dated 1/7/25 documents R24's Left Plantar Heel Diabetic wound with Calcaneus bone exposed as initiating in facility on 7/24/24 as having slough and necrotic tissue with yellow, increased purulent drainage, foul odor and measuring 12.0 centimeters (cm) long by 6.9 cm wide by 1.0 cm deep. This same log documents an antibiotic was started for Methicillin Resistant Staphylococcus Aureus (MRSA) of R24's Left Plantar Heel wound. R24's Treatment Administration Record (TAR) does not document R24's Left Plantar Heel wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 dressing change was completed on 1/3, 1/5, 1/6, 1/10, 1/12 and 1/17/25. Level of Harm - Actual harm R24's Nurse Progress Noted dated 1/9/25 at 9:39 AM documents Interdisciplinary Team (IDT) met to discuss R24's behaviors with no refusals of care noted. Residents Affected - Few On 1/14/25 at 10:45 AM R24 was sitting in her wheelchair with her Left foot on a stationary foot pedal. R4's Left foot and ankle were wrapped in gauze that was completely saturated with yellow drainage. R4's gauze dressing was saturated from the upper ankle area to the toes. On 1/14/25 at 11:20 AM V4 Registered Nurse (RN) completed R24's dressing change to her Left Plantar Heel Diabetic Ulcer. V4 RN did not use hand hygiene, nor change gloves after removing R24's saturated, contaminated dressing prior to cleansing R24's entire Left Plantar Heel open wound. R24's prior dressing of a four inch long by four inch wide blue absorbent pad, a white six inch long by four inch wide absorbent pad and an entire roll of gauze were all saturated with yellow drainage. R24 did not have any intact skin on the entire bottom of her Left foot from the pads below the toes to the heel and expanding the entire width of R24's foot. R24's Heel bone was exposed. On 1/15/25 at 9:45 AM R24 was sitting in her wheelchair with her Left foot on a stationary foot pedal. R4's Left foot and ankle were wrapped in gauze that was completely saturated with yellow/pink drainage. R4's gauze dressing was saturated from the upper ankle area to the toes. On 1/14/25 at 10:50 AM R24 stated the staff don't always change her Left Plantar Heel dressing like it is supposed to be done by the Physician order. R24 stated the dressing changes are 'hit and miss'. R24 stated, Look at my (Left) foot. It is soaked. I just got done with an antibiotic for that wound. You would think they (staff) would at least keep it clean. I would do it myself, but I can't reach my foot. On 1/14/25 at 11:40 AM V4 Registered Nurse (RN) stated she should have changed her gloves in between removing R24's old dressing and cleansing R24's Left Plantar Heel open wound. V4 RN stated cross contaminating R24's wound could cause her wound to become re-infected. V4 RN stated R24's dressing was saturated with not only wound drainage but also with urine. V4 stated R24 was incontinent of urine which contaminated her Left Heel wound. V24 RN stated R24's prior dressing had a strong urine odor. V4 RN stated staff should have provided incontinence care for R24 so that the urine did not contaminate R24's dressing and/or open wound. On 1/16/25 at 11:00 AM V2 Director of Nurses (DON) stated licensed nurses are expected to follow the physician orders for R24's dressing changes to her Left Heel. V2 DON stated R24 admitted to the facility in March 2024 with this same wound, it resolved and after two months it reappeared in July 2024. V2 DON stated R24's Left Plantar Heel open wound is categorized as a Diabetic Ulcer and started in July as a small 4.0 cm area on her Left Heel and has worsened to cover her entire bottom of R24's foot. V2 DON stated R24 has been on antibiotics via a Peripherally Inserted Central Catheter (PICC) line for this same wound in the recent past and was just on Amoxicillin 875 mg from 1/3/25-1/13/25 for the same Heel wound. V2 DON stated the staff should be very careful with all resident wounds, but especially with R24's Left Heel open wound to no contaminate it due to this could cause another infection. On 1/17/25 at 2:00 PM V1 Administrator stated the staff failed to monitor R24's Left Heel wound by not providing incontinence care timely to not allow R24's urine to contaminate R24's Left Heel open wound. V1 Administrator stated R24 can be non-compliant, but it is the responsibility of the staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm to make sure R24's dressing is kept clean and dry. V1 Administrator stated the facility does not have any documentation that shows the staff were monitoring R24's wound, documenting treatments were completed as per the Physician order or implementing care plan interventions to reduce the risk of R24's wound worsening. Residents Affected - Few The facility policy titled Wound Care revised 11/9/2018 documents staff are to apply gloves, remove dressing to be changed and discard, then remove gloves and discard. Perform hand hygiene, apply new gloves and clean wound bed per order. The facility policy titled Skin Prevention, Assessment and Treatment revised 5/2/2022 documents staff are to provide incontinence care after each incontinent episode, keep skin clean and dry. The goal of wound care of to protect the ulcer from contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to maintain safe storage of oxygen cylinders by failing to secure an oxygen tank to prevent being tipped over. This failure effects one resident (R23) out of six reviewed for accidents on the sample list of 27. Findings include: On 1/15/25 at 11:30 AM, there was an E type (3 feet tall, 5 inches diameter, containing between 2,200 and 3,000 pounds per square inch of gas pressure) free standing and not secured in any manner inside the doorway of R23's room. R23 was reclining in bed approximately 10 feet from the oxygen cylinder. On 1/15/25 at 11:35 AM, V1, Administrator, and V2, Director of Nursing, both confirmed oxygen tanks should not be left free standing on the floor without some kind of securement. V1 made an exclamation of, Oh no, why? The facility policy Oxygen Administration and Storage dated 3/8/22 documents E tanks must be secured in a holder. The tank may never be left unsecured at any time. This policy further documents oxygen cylinders must be stored in accordance with the NFPA (National Fire Protection Association) regulations. The current (2024) NFPA regulations to ensure safe handling and operation of oxygen cylinders documents to use racks or chains to secure oxygen cylinders (tanks). On 1/15/25 at 11:45 AM, R23's Nurses Note dated 1/9/25 documents R23 had an episode of low blood oxygen levels on 1/9/25 but had no documented use of any oxygen since that date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to properly label medications and failed to monitor expiration dates on medications administered for one (R4) resident out of nine residents reviewed for medication administration in a sample list of 27 residents. Findings include: The facility policy titled Administering Medications revised October 15, 2023 documents medications shall be administered according to Physician's written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. The facility policy titled Storage, Labeling of Over the Counter Medication, Destruction and Disposal of Medication revised 11/9/2021 documents no discontinued, outdated or deteriorated medications shall be available for use in the facility. Expired medications are to be removed from areas medication carts prior to or at the time of expiration. Medications must be dated upon opening the container, however it may be stored in an individual resident section (of the medication cart) and used for all residents. 1. R4's Physician Order Sheet (POS) dated January 2025 documents a physician order for Zinc Gluconate 50 milligrams (mg), Multivitamin daily, Ibuprofen suspension 100 mg/1 milliliter (ml) give 10 ml, Pantoprazole suspension 4 mg/1 ml give 10 ml per Gastrostomy Tube (G-Tube). On 1/16/25 at 9:30 AM V12 Licensed Practical Nurse (LPN) administered 10 milliliter (ml) of R4's Pantoprazole suspension which had a sticker on the back side of the bottle that read Do Not Use after 1/4/25. V12 LPN administered 10 ml of R4's Ibuprofen suspension. This same bottle of Ibuprofen did not have a medication instruction label. V12 LPN administered Zinc Sulfate 220 mg to R4. V12 administered R4's multivitamin. from a bottle of stock multivitamins with no open date documented on the bottle. On 1/16/25 at 12:30 PM V12 Licensed Practical Nurse (LPN) stated she did not notice the difference between R4's Medication Administration Record (MAR) instructing to administer Zinc Gluconate 50 mg and R4's medication card of Zinc Sulfate 220 mg. V12 LPN stated she should have noticed the difference and questioned R4's Zinc order prior to administering. V12 stated she did not see the sticker on the back of R4's liquid Pantoprazole bottle that ready Do Not Use after 1/4/25. V12 stated R4's Pantoprazole originally comes in a powder form and the pharmacy reconstitutes it to a liquid form. V12 stated because of this the liquid reconstituted form expires much faster. V12 stated she should have seen this and will get the bottle replaced so that no one else makes that error. V12 LPN confirmed there was no label on R4's Ibuprofen suspension. V12 LPN stated she saw that the house stock bottle of Multivitamins did not have an open date. On 1/16/25 at 1:35 PM V2 Director of Nurses (DON) stated all resident medications should have a label. V2 DON stated licensed nurses should not administer expired medications or medications that the expiration date is unknown. V2 DON stated these errors would not be a medication error but definitely would be medication labeling errors. V2 DON stated anytime a house stock bottle of medication is opened, the nurse should write on the bottle what date it was opened so that other nurses will know (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few when to dispose of that bottle. V2 DON stated V12 LPN should have notice the difference in R4's POS order for Zinc Gluconate and the medication card that read Zinc Sulfate. V2 stated this is again another labeling issue due to the facility recently changed pharmacies and the new pharmacy labeled the medication card for R4's Zinc Gluconate as Zinc Sulfate due to a pharmacy exchange. V2 DON stated V12 LPN did not administer the wrong medication but should have questioned the label being different from the POS. On 1/16/25 at 2:45 PM V15 Registered Pharmacist/Pharmacy Manager stated there is no significant clinical difference between Zinc Sulfate 220 mg and Zinc Gluconate 50 mg. V15 stated administering Zinc Sulfate 220 mg instead of Zinc Gluconate 50 mg would not be considered a medication error but should have been questioned by facility staff prior to giving. V15 stated this is a therapeutic pharmacy exchange. V15 stated administering expired Pantoprazole would also not be considered a medication error at that point but should have been noted by the facility staff and a new bottle obtained. V15 stated all medications should have a label including the name and administering instructions. V15 stated any medications that the facility provides should follow the facility medication labeling policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident record was complete for one (R48) resident out of one resident reviewed for closed records in a sample list of 27 residents. Findings include: R48's Electronic Medical Record (EMR) documents R48 was admitted to the facility on [DATE] and discharged on 10/21/24. R48's Electronic Medical Record (EMR) does not include Physician Orders, Nurse Progress Notes, Physician Progress Notes, Social Service Progress Notes, R48's weight and vital signs, Activities of Daily Living (ADL) charting and Assessments. On 1/14/25 at 2:00 PM V1 Administrator stated the facility is unable to provide documentation of R48's stay at facility due to a recent change in ownership. V1 stated R48 discharged on 10/21/24 to another skilled facility per R48's request. V1 Administrator stated whatever information is documented in the EMR is the only information the facility can provide. V1 stated R48's EMR is incomplete, and the facility has no paper documentation of R48's stay. V1 Administrator stated there is no policy for this, but it is known that the facility is expected to have complete medical records of all residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and when administering medications to residents who are COVID-19 positive on Droplet and Contact Isolation Precautions for two of five residents (R38 and R20) reviewed for Infection Control in a sample list of 27 residents. Residents Affected - Few Findings include: The facility policy titled Administering Medication revised 10/15/23 documents adherence to established facility infection control procedures shall be followed during the administration of medications. 1.) R20's Minimum Data Set (MDS) dated [DATE] documents R20 as severely cognitively impaired. This same MDS documents R20 is dependent on staff for assistance with eating. R20's Laboratory Report dated 1/6/25 documents R20 tested positive for COVID-19. R20's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 for (R20) of COVID Positive--COVID-19 Room. Isolate (R20). Standard, droplet and contact isolation every shift. All services provided in room. R20's Care plan does not include a focus area, goal nor interventions for R20's COVID-19 Contact and Droplet isolation precautions. On 1/14/25 at 12:48 PM V8 Certified Nurse Aide (CNA) did not wear gown nor gloves when assisting R20 to eat her lunch meal at a table by the nurses station. R20 was sitting at a table feeding herself her lunch. V8 CNA walked over to R20 without washing hands, or using hand hygiene, picked up R20's contaminated spoon and assisted R20 to finish eating her lunch. On 1/16/25 at 12:10 PM V8 CNA stated she did not know she was supposed to wear gloves when providing feeding assistance to a COVID-19 positive resident (R20). 2.) R38's Lab Report dated 1/6/25 documents R38 tested positive for COVID-19 on 1/6/25. R38's Physician Order Sheet (POS) dated January 2025 documents a physician order starting 1/6/25 and ending 1/16/25 of COVID Positive--COVID-19 Room. Isolate (R38). Standard, droplet and contact isolation. All services provided in room. On 1/15/25 at 11:51 AM V6 Licensed Practical Nurse (LPN) did not wear an N95 mask, gloves nor gown while she administered R38's scheduled noon medications. Signs for Droplet Precautions and Contact Precautions were posted outside R38's room door. A bin was sitting outside R38's room door with Personal Protective Equipment (PPE) supplies. On 1/15/25 at 11:55 AM V6 LPN stated V6 was aware that R38 is currently on Droplet and Contact Isolation Precautions due to being positive for COVID-19 and should have worn the appropriate PPE. V6 stated V6 could contaminate other residents by not wearing the proper PPE for COVID-19 precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146117 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Casey Rehab and Nursing 100 N.E. 15th Casey, IL 62420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm On 1/17/25 at 2:00 PM V2 Director of Nurses (DON) stated staff should wear the proper Personal Protective Equipment (PPE) when providing feeding assistance and/or medications to any COVID-19 positive resident. V2 DON stated gloves should be worn to help prevent the spread of COVID-19 and any other organism. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146117 If continuation sheet Page 12 of 12